The President's Health Care Speech: Some More Reactions

Thu, 10 Sep 2009 14:45:14 +0000

The President's speech raises a few more questions in my mind. In no particular order, here's what I'm wondering:

1) There are references in the speech to reducing costs in Medicare and Medicaid to help pay for the bill. Why will there still be a need for Medicaid for the non-elderly population if this plan goes forward? I thought that everyone was going to be eligible for the public option and subsidies would be given to make it affordable for those with low income. So why would anyone be on Medicaid if they weren't in a nursing home?

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2) The President said that he was serious about not signing a bill "that adds one dime to our deficits -- either now or in the future." He said:

And to prove that I'm serious, there will be a provision in this plan that requires us to come forward with more spending cuts if the savings we promised don't materialize. Part of the reason I faced a trillion dollar deficit when I walked in the door of the White House is because too many initiatives over the last decade were not paid for – from the Iraq War to tax breaks for the wealthy. I will not make that same mistake with health care.

So this is the usual procedure of including a trigger in the bill to cut costs if they appear to be getting out of line. These triggers simply don't work -- Congress finds away around them if they involve any pain to anyone. So I don't beleive this is effective at all. I would be persuaded if the implementation of the costly parts of the proposal were delayed until after the savings had been realized.

3) On the subject of whether reform would cover illegal immigrants, the President said:

There are also those who claim that our reform effort will insure illegal immigrants. This, too, is false – the reforms I'm proposing would not apply to those who are here illegally.

I don't believe this one either. The most obvious reason is that there was vocal disagreement in the chamber after he said this -- if this provision is ever expressed in a bill that passes the House or Senate, it is sure to be stripped out in the conference committee. Another reason is that to enforce this, we would know who is an illegal immigrant when he or she shows up requesting care and is not in an otherwise universal system. So how's that going to work? Some states will presumably look to formally include them in their systems, like they do with drivers' licenses, and in the rest of the places they'll get the same treatment they currently do.

You may also recall that the immigration debacle in 2005 was also a case where the government was unable to do the hard stuff, like securing the border, in advance of the easier stuff, like normalizing the treatment of illegal immigrants.

4) I still haven't heard or read anything about the details of the insurance reforms; specifically, how will we implement the key combination of community rating, guaranteed issue, and ex post risk adjustment. The private system cannot work without them.